Match Hype Hinders Health Access Solutions

In this time of avoiding the Truth, perhaps primary care training will be exposed to the truth as well. Each year the annual residency match generates numerous promotions of various types of programs as being primary care solutions. Sources low yield for primary care are not good sources for care where needed. The Match may indicate more medical students who begin training in primary care, but few will enter primary care and even fewer will stay in primary care.

Claims of nurse practitioner and physician assistant solutions for primary care are just as spurious. Those entering primary care and remaining in primary care continue to fall to lower levels. 

This year the claims of international graduates as solutions for underserved areas are prominent. About 50 - 90% of the services provided where the underserved need care are provided by primary care. International graduates fail as good sources of care where needed due to

  • 20% loss to home or other nations
  • 45% choosing lowest primary care yield in internal medicine
  • short periods of service in underserved areas
  • lowest percentages found in areas lower to lowest in concentrations of physicians

Measurements over an entire career are important. Short term measurements based on the first few years after residency are inaccurate and lead to promotions of poor solutions for care where needed  and primary care. 

The financial design absolutely prevents primary care from improving in delivery capacity, especially where most Americans are found - the Americans with the least health care workforce available for their basic care.

Primary Care Delivery Over a Career

The Match each March has little to do with primary care delivery. More graduates of primary care training enter other careers outside of primary care. Training in a residency or nurse practitioner program with a primary care title matters little. 
Primary care delivery over a career is about 

  • entry into primary care, 
  • retention in primary care, 
  • remaining active as a primary care clinician, and 
  • volume of primary care delivered. Each of these areas is shaped substantially by a financial design. 
The best financial designs with more revenue and less cost of delivery

  • Encourage more to enter primary care training
  • Facilitate more that enter primary care after such training
  • Retain more primary care graduates in the same practices and within primary care for better continuity, less turnover, more primary care experience, and more efficient/effective practice
  • Reduce rapid confusing change
  • Improve productivity
  • Enhance advanced primary care functions such as integration, coordination, outreach, and special needs patients and populations.
The current design provides the least support for primary care and offers the most opportunities month after month to leave for a different career with better support, better pay, a less confusing role, and lesser complexity. There are many consequences of inadequate financial design

Those who promote solutions for primary care that are not based on improved finances - are delaying the solution for most Americans, the most needed solution where care is most needed, and the services most increasing in demand.

Comparisons of Primary Care Delivery Over a Career

Family physicians are most likely to enter and remain in primary care and are most likely to remain active and also have top volume. Internal medicine, physician assistant, and nurse practitioner graduates are substantially limited in primary care delivery.

Past graduates were more likely to be retained, were more likely to be active, had longer careers, and were able to deliver more volume. Newer graduates have been moved the opposite direction by financial designs. The Standard Primary Care Year is a measure developed to indicate the future career contribution of a graduate. The past graduates have data from the AMA Masterfile and from 

Primary Care Retention % Active Career Years Volume Adjustment SPCYrs Measure
FM Past Graduate 0.9 0.8 35 1 25.2
FM Present Graduate 0.7 0.8 33 1 18.5
Pediatric Graduate 0.35 0.75 33 1 8.7
Nurse Practitioner0.45 0.6 24 0.85 5.5
Physician Assistant 0.25 0.75 33 0.85 5.3
Internal Medicine 0.15 0.75 33 0.9 3.3
IMG Internal Medicine 0.15 0.65 33 0.9 2.9
Exclusive Med School IM Grad 0.08 0.8 33 0.9 1.9

Least Primary Care Per Grad 2 to 6 Standard Primary Care Yrs per Graduate

The lowest yield sources of primary care require the most graduates for any type of primary care delivery contribution. It takes about 5 internal medicine graduates to contribute the same primary care as a family medicine graduate and two from IM for the same primary care as a nurse practitioner or physician assistant graduate.
  • Internal medicine graduates have collapsed with regard to primary care careers. Few enter and fewer remain. The retention is already less than 15% and is less than half of this for graduates of exclusive medical schools. About 10 - 15% primary care for a career is the best that can be expected as internal medicine declines to less than 30,000 for a primary care workforce by 2025 or 2030. Internal medicine is already past 40,000 for hospitalist workforce. In Standard Primary Care Years this translates to only 3 to 5 Standard Primary Care Years in a career.
  • International medical graduates are about 45 - 50% found in internal medicine training. This is also a career that facilitates departure from the US to other nations. About 20% depart the US after training to reduce the result. IMG Internal Medicine is small in contribution despite many graduates. 
  • Nurse practitioner graduates enter the workforce late for only 24 year careers compared to 33 for physicians, have lowest activity at 60%, and only half remain in primary care for the same low contribution as internal medicine at about 5 to 6 SPCYrs.
  • Physician assistants are down to just 15 - 20% in primary care with career length same as physicians but only 70% active and somewhat lower volume for about 3 to 5 SPCYrs.
Medical schools most exclusive in origins and scores also have fewest family medicine graduates and the internal medicine graduates are documented as less than 8% for primary care retention. Pediatric graduates from the most exclusive schools also fail to remain in primary care at lowest retention. About 30% of US medical schools yield very little primary care at all at only 1 to 2 Standard Primary Care Years per graduate. Some of these schools are top rated in primary care in US News and other ratings.

Top Ranked Primary Care Schools Often Contribute Least to Primary Care Delivery

Expansions of NP and PA annual graduates have been negated by primary care retention declines for little if any gain in primary care delivery capacity and massive increases in specialty and subspecialty workforce. Expansions have failed for the purpose of primary care enhancement for decades.

Minimal Primary Care Contributions at 8 - 11 Standard Primary Care Years
  • Pediatric contributions are limited by low primary care retention at 30 - 35% and lower activity compared to other physicians for only 8 - 11 SPCYrs.
  • Medicine Pediatric contributions also have low primary care retention at 35% and tend to melt into internal medicine over time.
Moderate Primary Care Contributions

There are no more major primary care contributors. Family medicine is all that remains of moderate primary care result, but even family medicine is slipping away under the assault of payments too low with costs of delivery too high, the most complex patient care, and rapidly aging populations as well as deteriorations of mental health, basic surgical services and dental care for even greater burdens.
  • Two decades ago family medicine graduates were most reliable at over 90% active for a career in family practice positions with highest volume and 35 year careers for over 25 Standard Primary Care Years per graduate.
  • Recent graduates have less than 70% retention in primary care for 33 year careers with 85% active for only about 17 - 20 Standard Primary Care Years.

Family medicine can claim an increase from 3000 to 3200 annual graduates but these 3200 graduates will only deliver the primary care of 2600 of the past graduates for a net loss in primary care delivery.

FM was once 95% found in family practice positions but this is down to 70% of active grads. Better paying and better supported positions are capturing 12% - 15% of FM for ER, about 5% - 6% each for urgent care and hospitalist positions, and a few percentage points for geriatrics, sports medicine, and surgical specialties.

How can you increase primary care delivery capacity 
with stagnant revenue and accelerating costs of delivery from multiple sources?

The Financial Design Kills Health Access and Kills Tens of Thousands via Access Barriers a Year
  • Health Info Tech at tens of thousands more a year
  • Increasing Cost of Primary Care Turnover
  • Decreasing Morale and Productivity
  • Increasing Supply, Insurance, and other costs
  • Primary Care Medical Home and other Certifications at $80,000 plus a year



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